Roots Child Information Form
This information will be kept on hand at Roots for facilitator use.
Basic Information
Child's Full Name
Your answer
Nickname
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Mailing Address
include zipcode please
Your answer
Parent Information
Parent/Guardian 1 Name
Your answer
Parent/Guardian 1 Cell
Your answer
Parent/Guardian 1 Email
Your answer
Parent/Guardian 2 Name
Your answer
Parent/Guardian 2 Cell
Your answer
Parent/Guardian 2 Email
Your answer
Additional Parent Phone Numbers
Please label "home," "mom work," etc
Your answer
Health and Wellness Information
Please list and describe any allergies
Your answer
Please describe any food preferences/eliminations of your child or family. Please describe with details like "never," "always," "most of the time" etc.
I.e. Our family always eats vegetarian. Lauren eliminates gluten most of the time. We prefer our child not eat dairy, but on occasion it is okay.
Your answer
Medical Provider Name
Your answer
Medical Provider Phone Number
Your answer
Emergency Contact 1 Name and Phone Number
Name (relationship) phone number i.e. Addie Newland (grandmother) 704 123 4567
Your answer
Emergency Contact 2 Name and Phone Number
Name (relationship) phone number i.e. Addie Newland (grandmother) 704 123 4567
Your answer
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